TORONTO — Eleazar Noriega, a repeat sex abuser pediatrician, should be stripped of his medical licence to reflect the profession’s “abhorrence” at his “gross sexual exploitation” of a vulnerable 15-year-old female patient, says the College of Physicians & Surgeons of Ontario.

Dr. Noriega, 70, subjected the girl to “protracted sexual stimulation under the guise of a medical examination on the occasion of her last visit to him at the teen clinic at the Hospital for Sick Children” in Toronto in 1979.

He has shown no evidence of remorse, the CPSO prosecutor noted, and the passage of time should not be seen as a mitigating factor. Likewise, another finding of sex abuse against him in 2003 “demonstrates that this is not an isolated occurrence.”

“She was the epitome of the vulnerable patient,” said the prosecutor, Amy Block. “There are no mitigating factors.”

The victim testified Dr. Noriega said he needed to check if she was sexually active. He touched her clitoris for two to three minutes, causing her to have an orgasm, as if he were “scrubbing a spot off a pot.”

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Dr. Noriega kept his head down during the legal arguments before the tribunal that will decide his fate, barely paying attention, and at times reading a paperback copy of The Progress of Love by Alice Munro.

This case of abuse only came to light in 2008, when police laid charges against Dr. Noriega for allegedly abusing an eight-year-old patient, and the 1979 victim heard his name on the news. Those two cases were tried together. After lengthy proceedings, only the 1979 complaint was upheld by the CPSO’s discipline committee.

Both were also the subject of criminal charges laid by police, but dropped before trial by the Crown.

Dr. Noriega had already been found guilty of sexual abusing another female patient in 2002, when she was 17. He was tried criminally for that but acquitted by a jury.

Given the political climate in which the Ontario government has called for review of the CPSO’s sex abuse policies, the case for revocation would seem to be strong.

In fact, if Dr. Noriega had committed this same offence after 1991, the revocation of his licence would be automatic under the CPSO’s zero-tolerance policy. But because it happened 35 years ago, it has been prosecuted under the old legislation, and thus his licence might be saved.

His lawyer argued the more appropriate penalty would be a “lengthy” suspension of his licence, perhaps for a year, followed by reinstatement with conditions he not see female patients without a monitor, and post a notice to this effect in his office.

Dr. Noriega has been working under those conditions since 2003. In 2013, he was found to have violated them, “misled” a CPSO investigator, and taken a “cavalier” attitude to those serious restrictions, which were imposed after the first sex abuse finding.

His lawyer also filed letters of support from patients, saying they are “emblematic of his general reputation for good care and medical service.”

As a Mexican who immigrated to Canada in 1977, he sees many unilingual Spanish-speaking families who would otherwise find it hard to get a pediatrician.

A decision is not anticipated for several weeks. The CPSO is also seeking more than $40,000 in legal costs.

TORONTO — As Ontario reviews its policies on sexual abuse by doctors, the case of Eleazar Noriega shows how drastically wrong such cases can go, and the lasting effects they have on victims.

On Wednesday, 35 years after Dr. Noriega, 70, molested a teenage female patient at a Toronto clinic, the College of Physicians and Surgeons of Ontario is to finally hear arguments about his penalty. Options range from a reprimand to a licence suspension — which would be his second for sexual abuse — to full revocation. Even under the college’s policy of “zero tolerance” for sexual abuse, little about his fate is certain, and given his ongoing appeal, this penalty might not be the final word.

As an illustration of the devastating scope of his misconduct, however, the key moment came six years ago, when police laid charges, later dropped, alleging Dr. Noriega molested an eight-year-old girl in his uptown Toronto office, based on a complaint by her mother, who claimed to have witnessed it.

Two women read that news, and for each it triggered powerful feelings of regret, because both had been molested by Dr. Noriega under the guise of medical exams, more than 20 years apart, and neither felt they did as much as they could to stop it happening to someone else.

‘It made me feel sick, that if I had come forward those little girls wouldn’t have been molested too’

As one victim put it, he created “a cycle of blame for us.”

“It made me feel sick, that if I had come forward those little girls wouldn’t have been molested too,” said the 1979 victim, in testimony before the college.

“I felt blame, too, like it was my fault it happened again, I didn’t do enough,” said the other victim, who was abused in 2002 when she was 17.

“I know he was grooming me,” said the woman, now 30, who was then a high school student with a troubled home life, and now has a successful career in Toronto television media. In an interview, she described the progressive way he touched her and inquired about her personal life. She recalled one incident with a serious sunburn. “I just remember the way he was putting cream on my back was too much.”

The identities of both women are protected. Criminal charges involving the girl were dropped by prosecutors, and dismissed as not credible by an earlier college tribunal.

A pediatrician, Dr. Noriega had seen the 2002 victim all her life, and as she grew older, she felt he was scheduling more frequent appointments, and filling his chart with inquiries about her sexual behaviour and drug use.

“I think he used it as ammunition to make it seem like I was this unstable person,” she said.

The abuse she endured is strikingly similar to that described by the 1979 victim, which also led to a criminal charge that was dropped by the Crown before trial. The younger woman has also come to realize how similarly vulnerable they were.

Her abuse spanned two appointments in 2002. The first was confusing, and made her wonder if she was over-reacting. On the second, she deliberately dressed to “make myself look unappealing,” and only went because she was so ill. Under the pretence of examining her for bronchitis, Dr. Noriega molested her with his hands on her breasts and genitals, under her underwear, with no glove. It seemed to her he was trying to arouse her. It was traumatizing, and it led her to file complaints with police and the college.

She developed post traumatic stress disorder, which was manifesting in sleeplessness and nightmares, often on the theme of Dr. Noriega coming to murder her or her younger sister with a knife. A year later, her friend’s younger sister, Holly Jones, was the victim of a high profile murder motivated by pedophilia, and the doctor and murderer became linked in her mind.

“I don’t think I fully faced how much it affected me,” she said. “Mostly [now] I try to avoid the whole situation. … My revenge is that he knows what he did, and it’s going to come back around sometime.”

‘My revenge is that he knows what he did’

It has been a long time coming. Before the criminal trial, the college accepted Dr. Noriega’s plea of “no contest” to her complaint of sexual abuse, and suspended his licence for nine months, and made him take a course on “boundaries.”

Soon after, at the criminal trial, Dr. Noriega’s lawyer used his records to cross-examine her on everything from drug use to the colour of her thong underwear. The jury acquitted him of sexual assault.

“I remember they wouldn’t really look at me,” she said of the jurors.

This current case — based on the 1979 complaint, which was first reported in 2008 — is similarly convoluted. The college first heard it jointly with the complaint about the eight-year-old girl, leading to conviction only on the 1979 complaint. But Dr. Noriega appealed, won a new hearing, and was found guilty again of the 1979 complaint. A key issue was whether the 2002 victim could testify to establish a pattern, or whether Dr. Noriega’s settlement meant her case could never again be used against him.

That issue is likely to factor in his appeal, because she did testify at the second tribunal, and she felt more confident than ever. Her attitude toward defence lawyers had changed. Once, she thought she was the only victim. Then she learned she was not.

As she put it, “I’m going to rise up this time and you’re not going to push me around, because I’ve been bullied through this whole situation.”

EDMONTON — Medical researchers at the University of Alberta has two words of advice about the recommendations on medical talk shows: be skeptical.

In a new study in the British Medical Journal, they found only one-third of the recommendations on Dr. Mehmet Oz’s hugely popular syndicated show and about half those on The Doctors were supported by believable or somewhat believable evidence.

Rather, the advice was too general and too broad to be of much value, with generic statements like “Everyone should take this supplement because it’ll improve your brain power” or “Take this to reduce inflammation,” said Dr. Tina Korownyk, the study’s lead author.

Such statements are “a good way to say something is beneficial without committing to any specific benefit.”

The U of A study had two goals: to see if the TV doctors’ recommendations were supported by evidence published in scientific journals; and what information — if any — the celebrity doctors provided with the recommendations, such a quantifiable, specific benefit, risk, or cost.

‘We haven’t really researched why people are watching these shows. If it’s for entertainment, I can’t say it’s harmful’

The research team recorded every episode of the shows that aired in 2013; then two researchers independently watched 40 randomly selected episodes of each show, recording data on the topics, recommendations and who made them.

In a second round, two different researchers watched the same episodes, looking for any details about the benefits of the recommendations and whether these were quantified in any way.

The team’s findings indicate much of the advice is not backed by medical research and “the details around the recommendations are often lacking.”

One of the reasons for the study was the shows’ influence. Many primary-care physicians say patients ask them questions about the medical advice they see on TV — often when they are already following the recommendations.

In June, Dr. Oz told the Edmonton Journal he takes his role as one of the leading celebrity health voices in North America “very seriously.”

The job is “a huge mental responsibility. For a lot of folks, you end up becoming the primary caregiver. You’re giving a lot of advice that historically they would have gotten from their doctors. Now, that beginning conversation starts in the [TV] studio and they take the conversation to the doctor’s office.”

That same month, a U.S. Senate panel scolded him for giving people false hope with the “miracle” weight-loss supplements he promotes on the show. Dietary advice accounts for nearly 40% of his recommendations, the U of A study found.

The Dr. Oz Show is one of the top five talk shows in the United States, with about 2.9 million viewers a day, while The Doctors has 2.3 million viewers.

Dr. Korownyk isn’t advising people to stop watching.

“We haven’t really researched why people are watching these shows. If it’s for entertainment, I can’t say it’s harmful,” she said.

Still, viewers should be wary of what those good-looking doctors in scrubs suggest as treatments.

The findings will help physicians talk to patients about what they’ve learned on TV, and should reinforce to the general public how important it is to take that advice at face value, Dr. Korownyk said.

“You need to know all those other details before you begin any type of intervention.”

The patient was gravely ill, but a lengthy note by nurses at a Halifax hospital focused on the person’s next of kin. The relative, they complained, was making trouble, demanding aggressive treatment that seemed inappropriate — a source of frequent tension in Canadian health care.

Stephen Workman reviewed the chart, called the relative and passed on grim but straightforward news.

The patient was likely to die, and treatment such as cardio-pulmonary resuscitation [CPR] would offer little help, the internal-medicine specialist at QEII Health Sciences Centre recalls informing the family member.

“ ‘Oh, we were never told that,’ ” the person responded, the dispute suddenly ending. “ ‘That’s all right then.’ ”

The surprising encounter embodied an idea some physicians say could go a long way to lessening the conflict and discomfort that marks many Canadians’ deaths.

As controversy builds around euthanasia, funding for palliative care and the limits of life-extending technology, these doctors advocate a bit more plain speech.

Instead of tip-toeing around the question, be direct, they argue. Rather than telling someone their mother is “seriously ill,” why not explain gently that the woman is dying, asks Dr. Workman, on a mission to transform the language around end of life.

Being frank can make people more willing to consider palliative care in hopeless cases, or at least be more realistic about the benefits of further treatment – and motivate health professionals, the physician said.

“We like euphemisms for death,” he said. “Dying patients, they’re not dying, they’re ‘failing to respond,’ or ‘they’re doing badly.’ … [But] If you say ‘This patient may well be dying, and I’m going to be looking after them for what in all likelihood will be their last week or two of life,’ then I think you have to step up to the plate.’ ”

Care of people in their final months or days is an increasingly pressing — and controversial — issue, not least because of demographics. The number of Canadians dying yearly is projected to climb 40% in the next dozen years, their final 12 months accounting for as much as a quarter of health spending.

One study concluded that seven of 10 hospitalized elderly people wanted comfort care as opposed to life-prolonging treatment, yet most ended up in the intensive-care unit. Both the Health Quality Ontario agency and the province’s ombudsman called this week for more and better palliative care.

At the same time, hospitals and families have repeatedly clashed over the issue, relatives typically wanting all the stops pulled out, and doctors feeling that continued treatment is futile and harmful.

Some disagreements may be intractable, others a function of communications breakdowns, say ICU doctors who spoke to the National Post this week.

“I do think we’re afraid of failure sometimes in the medical profession, and so probably do use language that we think is just being a bit gentle, when it’s not what we believe,” said Chip Doig, head of critical-care medicine at the University of Calgary. “If we truly believe that something is not curable, what it requires is time, what it requires is care to have a meaningful discussion with the family.”

Part of the problem is that health care has its own “industry slang” whose meaning is clear to doctors and nurses, but much less so to patients, he said. Tension often revolves, for instance, around “do not resuscitate” orders instructing staff not to perform CPR and other emergency procedures on a patient if his or her heart stops.

It is not only a negative term – signifying medical neglect to some lay people — but often misunderstood, Dr. Doig said. That is why he talks to families about performing “chest compressions” after cardiac arrest, not CPR, and that doing so could break several ribs and cause acute pain.

Likewise, he said he does not just discuss whether to put patients on a ventilator to help them breathe, but explains that it means forcing a tube down their throat, which could lead to pneumonia and other harms.

Meanwhile, there is a nascent movement to replace the term “do not resuscitate” with “allow natural death.”

‘If we truly believe that something is not curable, what it requires is time, what it requires is care to have a meaningful discussion with the family’

Some doctors hide behind euphemisms because they’re afraid of upsetting families or simply unsure of the prognosis, echoed Randy Wax, a critical-care physician at Lakeridge Health in Oshawa, Ont. Yet telling people their kin might “pass away,” rather than die, for example, can be a recipe for confusion, he said.

Dr. Wax relates the story of one family member who thought their relative was dead, when a nurse had only meant to explain the person had “passed” a tooth they had earlier swallowed, using the word as a euphemism for another unmentionable human act.

He said he often starts difficult ICU conversations by asking family members what they know. Sometimes, they are aware that death might be imminent; other times, such news is completely unexpected, he said.

Medicine tends to focus on treating individual ailments and communicating those plans to families — but without painting the big picture and all that it means, Dr. Workman said.

A U.S. study published in 2012 found that 69% of lung-cancer patients and 81% of colorectal cancer patients surveyed were under the misconception the chemotherapy they had undergone months earlier would likely cure them.

Dr. Doig recalls a recent patient with metastatic cancer, already in palliative care, who was about to undergo surgery for a perforated bowel that had triggered septic shock. The family initially agreed to the operation, but the surgeon and emergency doctors had not explained the septic shock would probably kill the patient regardless.

“They said, ‘We thought from the surgeon it was fairly easy to fix the hole in the bowel and he’ll be in the ICU overnight.’ ”

Dr. Wax said he would like to see more education of the public about the true meaning and limits of the treatments offered by technology-laden hospitals.

Family physicians and specialists who treat patients for serious, chronic illness also need training on how to prepare patients for the inevitable end, he said.

Dr. Workman is doing his best. He published a journal paper advocating more forthright end-of-life language, and teaches medical students his sensitive but candid approach.

Being plain-spoken can be refreshing to patients, he said, citing the elderly man he encountered at QEII, his illness clearly advanced. The physician asked what he’d like to know about his disease. The patient said he wanted to learn “what’s what,” and the physician hesitatingly replied that the man was probably dying.

Doctors must obtain the consent of patients or their families before deciding to turn off or withhold life-preserving treatments, Canada’s largest medical regulator says in a draft new policy that largely reshapes how end-of-life care is decided.

The blueprint, to be released officially Thursday, contrasts with the existing advice offered by Ontario’s College of Physicians & Surgeons — that doctors should avoid treatments they believe will be of no benefit or harmful to a gravely ill patient.

Regulators in at least two other provinces and in Britain have similar policies, stipulating essentially physicians have the final word on what kind of end-of-life treatment is most appropriate.

Recent legal rulings have raised questions about that approach, however, with one tribunal saying the Ontario guidelines were clearly at odds with the law.

‘I don’t think we want to be encouraging people to pursue futile treatments. That’s why we have emphasis on communication’

The new policy addresses those concerns, but still directs intractable disagreements to an independent board for a ruling and should not mean dying patients are kept alive in vain, said Carol Leet, the college’s president.

“I don’t think we want to be encouraging people to pursue futile treatments. That’s why we have emphasis on communication, to get people onside earlier in the process,” she said.

“There are studies that show the number of physicians who would want CPR [cardio-pulmonary resuscitation] done on them when they’re terminal is very low, because we understand how futile it really is.”

The draft policy also tackles what doctors should do if patients ask for help in committing suicide, arguing they should discuss their concerns about pain and other issues, rather than merely indicating assisted-death is against the law.

And it urges doctors to discuss end-of-life issues with patients long before they are at death’s door.

The proposals come amid growing debate over how to treat terminal patients and who decides if there is disagreement.

Key issues include when to impose do-not-resuscitate (DNR) orders — meaning staff will not try to revive a patient whose heart has stopped — and curtailing life-preserving treatments like ventilators (artificial breathing machines) and tube feeding.

Most situations are resolved amicably, but a steady stream of cases — where families have wanted every effort made to keep their loved ones alive and doctors have balked at providing what they considered futile and painful treatment — has ended up before judges or other adjudicators.

Last year, the Supreme Court of Canada ruled physicians in Ontario, at least, should get families’ consent before unplugging life support and turn to the province’s Consent & Capacity Board (CCB) for a ruling if there is no meeting of minds.

In a disciplinary case decided in September, Ontario’s Health Professions Appeal & Review Board said a Toronto hospital was wrong to change an elderly patient’s chart from “full code” to DNR without even consulting the man’s daughter. She arrived at his room as her father went into cardiac arrest, and nurses and doctors refused to perform CPR.

The college had cleared the physicians involved of any wrongdoing, but the board said they had committed serious misconduct and the agency should change its rules to be in line with the province’s law.

The current policy says when it is clear that a treatment will almost certainly not benefit or may be harmful to a patient, “physicians should refrain from beginning or maintaining such treatment.”

The new draft says physicians must get consent from the patient, or “substitute decision maker” if the patient is unable to voice his or her wishes.

In a separate section of the policy, it says that doctors should ultimately ask the CCB for a ruling if they and families cannot agree. No other province has such a tribunal.

The new proposals are much better than the old policy, said Mark Handelman, a health-care lawyer who once sat on the board. But they need to be more adamant about the ability of doctors to appeal to the consent board, as many of them are not even aware it exists, he said.

The result is that in virtually every intensive-care unit in Ontario, there is at least one case causing staff distress because doctors have given in to the family’s wish to keep their loved one alive futilely, said Mr. Handelman.

He also said family doctors should be paid a fee to discuss end-of-life issues with patients and have them set out their wishes in advance, potentially preventing clashes down the road.

A medical acronym, SHPOS, helps a doctor summarize a patient’s history in just five letters. But unlike emotionally neutral acronyms doctors use, such as LOL—little old lady—SHPOS is a derogatory term that describes a hospitalized patient who is felt by his doctor to be a “subhuman piece of shit.” The acronym has been around since at least 1980, when it was first mentioned in print, but must have existed long before it was memorialized in the journal Man and Medicine. Some doctors drop the SH prefix, going straight for POS, but the phrase “subhuman” is really where the expression gets it power. What makes a patient, formerly known as a human being, an SHPOS? An SHPOS becomes an SHPOS when a health care worker hates him.

The term is known to physicians everywhere, passed by word of mouth from resident to intern to medical student. Psychiatrist Abbey Strauss described the phenomenon in a 1983 paper: a patient who is “childlike, unreliable, occasionally arrogant, demanding, insensitive, self-centered, ungrateful, non-compliant, and wrongly motivated.” Strauss describes a type of SHPOS who might be called a “difficult patient.” His paper focused on the way physician and patient narcissism create the SHPOS interaction. As a psychiatrist with an interest in antisocial personalities, I would add to his description the words abusive, threatening, racist, misogynistic, and rageful.

Not surprisingly, the SHPOS is often alone in the world. He may have just been released from jail, or his loved ones may have refused to take him in. He may have been fired from his job or banned from seeing his children. On top of that, now he is ill. The SHPOS comes to the hospital in a state of social despair, isolated and unhelpable, and the only person left to absorb his rage is the health care worker who must care for him, no matter how hateful he is.

One doesn’t get called an SHPOS for nothing. Walk the hallways of a hospital in a tough neighborhood and you will see security officers, some of them armed, on every ward. Some patients require two officers to control their violence and threats—and these patients are not under arrest. Patients throw feces and full urinals at staff. They cut themselves with IV needles to express their disgust with the hospital diet. They prey on other patients who are too ill to defend themselves, stealing their cash and even the food from their trays.

Recently I was one of two doctors in a team meeting with a patient, a physician assistant, and a social worker. The purpose of the meeting was to clarify treatment goals, as the patient seemed unwilling to accept the medical staff’s recommendations and had announced he would not leave the hospital if his needs were not met. The patient was addicted to cocaine and wanted to be admitted to a rehab program, a laudable goal. Unfortunately, the patient’s insurance refused to pay. The patient found this difficult to accept, understandably, but rather than make the best of what he had to work with, he lashed out at the women in the room, the social worker and myself. He spoke to us with absolute contempt. He attacked me particularly as an unethical, uncaring, and lazy psychiatrist whose only agenda was to save the hospital money. His remarks were so unexpectedly and inappropriately hostile that the team was taken aback and took several minutes to collect itself and terminate the meeting.

While being berated, I was aware of my heart pounding, and of the effort it took not to retaliate verbally and physically for this assault. I maintained my self-control, but at a cost. For days I ruminated over the event. I imagined that my struggle to contain my own anger had damaged my cardiovascular health. I felt humiliated in front of my colleagues and unmasked as a weak person not competent to manage difficult patients. I thought of my parents’ pride when I became a doctor, and imagined what they would think if they knew about my actual daily experiences.

Thus an SHPOS was born. Prior to that meeting, he was a man with a serious drug problem who had come to the hospital for help. When he and I entered a dyad of mutual hatred, we lost ourselves. He was subhuman, and I was the doctor who loathed him.

These demoralizing encounters are commonplace in hospital medicine. Less often, but more dramatically, SHPOS behavior leads to serious injury. On one nursing unit at my hospital during the past year, a patient broke a nurse’s arm, and another ripped out a hunk of a physician assistant’s hair.

After the hair-pulling incident, which was unprovoked and terrifying to all who witnessed it, the outpouring of distress was shocking. Most of the physician assistants at my hospital are women in their 20s, many in their first jobs. Many are nonwhite. All described an atmosphere of continual sexual harassment and disrespect by patients. Many had been touched inappropriately, and all had been subjected to comments about their appearance. Most described feeling afraid to enter some of their patients’ rooms, and many would not enter a patient’s room alone.

No one is proud to call another person subhuman

More women than ever before are physicians. In addition, women are disproportionately represented in lower-paying, less prestigious “physician extender” positions, such as physician assistants and nurse practitioners. Nurses and nurse’s aides, at least at my hospital, are mostly female, as are social workers, care coordinators, and clerks. When a female clinician interacts with an angry misogynist who is now ill and vulnerable, dependent on women for lifesaving treatment, food, water, comfort, and company, the climate is ripe for the development of SHPOS behavior.

One thing that stands out about SHPOS behavior is its pointlessness. It doesn’t solve anything for the patient, and he doesn’t appear to derive pleasure from humiliating others. He expresses a bottomless need for care that can never be met, and punishes the health care worker in advance for failing him.

He lashes out, or clings to the caregiver, angrily refusing to leave. When he is finally escorted out by security, or escapes in the middle of the night with his IV still in place, he leaves the staff shaken. No one is proud to call another person subhuman.

Anne Skomorowsky practices psychosomatic medicine at New York-Presbyterian Hospital and is an assistant professor of psychiatry at Columbia University

Merle Ackie was in court this year on a matter literally of life and death.

Her daughter, Clescelia Ackie-Friday, had been in a vegetative state for more than two years, but the hospital wanted to unplug the 46-year-old’s ventilator and transfer her to a palliative ward.

Ms. Ackie would have none of it, convinced the woman was more responsive than doctors knew and a “miracle” would make her walk and talk again, if only she could be kept alive in the meantime.

It is the kind of dispute over end-of-life care that is roiling intensive care units (ICUs) and emergency wards across Canada as physicians, worried about prolonging death and suffering, clash with families who feel everything must be done for their loved ones.

But almost a year after a landmark Supreme Court of Canada ruling on end-of-life treatment, some experts say the balance in those disagreements has tipped, with physicians often reluctant now to push the point against the opposition of family members.

That is a change many relatives would welcome; one lawyer who represents both sides, however, calls it is a misreading of the court decision that is causing a regrettable fallout.

“I think doctors have concluded … they have no choice but to do everything that the family demands, and I don’t think that’s what the court said at all,” said Mark Handelman, a Toronto lawyer who specializes in health issues.

“The consequence I see is that we have people that in a literal sense we are torturing at the end of life because the doctors are just rolling over.”

Anand Kumar, a critical-care physician at the Winnipeg Health Sciences Centre, said the Ontario-focused ruling has left his colleagues there “more reticent about being aggressive in the face of family opposition.”

Elsewhere, the Supreme Court ruling has added to legal interventions in recent years that have generally made younger ICU doctors reluctant to challenge families who insist on continued treatment.

“They’re much less inclined to say that their view of medical ethics trumps their legal obligations,” said Dr. Kumar.

“More so as time goes on, some younger physicians are falling into, ‘This is just a job … if the court tells me to do it, I’ll do it.’ ”

If the pendulum is swinging in favour of family demands, that would be a bitter-sweet development for Joy Wawrzyniak, a retired Ontario nurse. Unbeknownst to her and against her wishes, doctors imposed a do-not-resuscitate (DNR) order on her severely ill father, who died in 2008. Last week, a disciplinary appeal board ruled they had violated Ontario law.

“I suspect … there are patients that this has happened to before and the families are not even aware,” said Ms. Wawrzyniak. “It’s not [physicians’] decision to make. They are only looking at themselves, their own opinions, and opinions vary from doctor to doctor.”

Disputes over unplugging life support or withholding emergency treatments like cardiopulmonary resuscitation (CPR) are undoubtedly only a fraction of total hospital patients, yet courts and tribunals have repeatedly had to grapple with them in recent years.

Central to the cases is the question of who has the final say over those patients’ treatment — medical staff or family members? To what extent, in other words, can loved ones demand procedures doctors argue are futile and possibly harmful?

Health workers and patient advocates hoped the debate would be resolved by the Supreme Court’s ruling last October in the case of Hassan Rasouli, a brain-damaged Toronto man in a “minimally conscious” state. Doctors wanted to remove him from the ventilator, his family objected.

The court offered some guidance, but hardly the final word. It said medical workers, in Ontario at least, must get consent of the patient’s “substitute decision maker” and if that is not possible, refer the issue to the province’s Consent & Capacity Board. The judgment revolved largely around Ontario law; its impact on other provinces is unclear.

Yet some in the system see signs of change, most noticeably in Ontario, but also elsewhere. It is difficult to empirically prove attitude shifts, but Mr. Handelman notes the Consent & Capacity Board would hear an end-of-life case every two to three months before the Rasouli judgment. Since then, activity seems to have slowed, suggesting hospitals are pulling back, says the lawyer, who once sat on the board.

And after a spate of court cases outside Ontario, where there is no such quasi-judicial tribunal to settle disputes, there is little evidence of any since the Supreme Court ruling.

‘The consequence I see is that we have people that in a literal sense we are torturing at the end of life because doctors are just rolling over’

It’s still uncertain what the decision means in other provinces, said Chip Doig, a University of Calgary critical-care specialist. He noted, though, a colleague was recently advised to agree to family demands and remove a DNR order on a terminally ill patient to avoid legal trouble.

“There seems to be an increasing tension between the perspective of physicians exercising their professional judgment … and regulatory bodies or tribunals saying, ‘Nope, too bad,’ ” he said.

Still, changes in how intensive care is delivered are by no mean wholesale.

While younger doctors may be increasingly reluctant to butt heads with families, Dr. Kumar said many physicians in Manitoba would still not hesitate to impose a DNR over relatives’ wishes if they deemed it necessary.

“What we do in the ICU, what we do in resuscitation, assuming the person regains consciousness, is ultimately painful and uncomfortable,” he said. “You don’t want to inflict this thing on a person unless you have some reasonable hope of success.”

Contentious cases can have a deep impact on the health-care system, said Dr. Doig, who has seen nurses quit the ICU after staff were forced to provide treatment they considered futile.

Barb Farlow, a patient-safety advocate in Toronto, has a different viewpoint: she learned only after her infant daughter died from a genetic disorder a DNR directive had been written on the girl’s chart.

Ms. Farlow said she understands the challenges facing ICU doctors, though she believes they stem largely from a lack of resources — the average ICU patient costs $3,000 a day to treat and units are often near capacity.

What is needed is a more transparent system, where doctors’ intentions are clearly spelled out to families, she said, citing a unique Texas law.

Among other steps, it requires hospitals to give families written notice they want to impose a DNR or withdraw life support and a chance to move the patient to another facility.

FotoliaThe average ICU patient costs $3,000 a day to treat and units are often near capacity.

Mr. Handelman stresses doctors are not obliged under the Rasouli decision to do whatever the patient’s families want. And they could likely avoid some conflict by laying the groundwork for end-of-life situations, he said.

That means in part giving plain-English explanations for the patient’s condition and asking in advance — before risky surgery, for instance — what the patient would want done if he or she ended up close to death.

Dr. Doig is skeptical, saying it is usually not a lack of medical information that leads to end-of-life disputes, but differences in values.

That appears to have been at least a factor in Ms. Ackie-Friday’s tragic case. She had been an independent and energetic woman before a genetic condition put her into respiratory arrest in 2011, causing her heart to stop and leaving her eventually in a vegetative state.

When doctors proposed late last year to disconnect her ventilator and move her to palliative care, her mother objected, saying the devoutly religious woman believed in miracles and would want the chance to benefit from one.

In a decision that was upheld this year by an Ontario court, the Consent & Capacity Board firmly sided with the physicians’ medical assessment.

“All of the medical evidence made plain that Clescelia had a very poor quality of life and the situation would not improve,“ it said.

“[She] was subjected to daily indignities through invasive medical procedures without increasing the likelihood that she would recover any awareness or consciousness”

Doctors at a major Toronto hospital violated the law by unilaterally imposing a do-not-resuscitate order on an elderly patient against his family’s wishes, an appeal board has ruled in an extraordinary clash over end-of-life care.

Douglas DeGuerre died from cardiac arrest at Sunnybrook Health Sciences Centre as his daughter, Joy Wawrzyniak, frantically tried to convince medical staff to save him, and health workers declined to help the severely ill war veteran.

In a case that dramatizes the debate over who has ultimate power in such cases – doctors or patients’ families — Ms. Wawrzyniak said she had only just learned that the “full code” response to emergencies she had requested on her father’s behalf had been over-ruled by a do-not-resuscitate (DNR) order, which meant CPR would not be attempted during cardiac arrest.

Ms. Wawrzyniak, a nurse, said Wednesday that Mr. DeGuerre, 88, was struggling to breath when she entered his room the day he died in 2008.

“My father said to me, ‘I’m drowning, I’m drowning.’ Those were his last words,” she recalled. “I grabbed the oxygen bag, and I tried to help my father while they all stood there and did nothing … I just couldn’t believe it.”

Ontario’s medical regulator has twice rejected Ms. Wawrzyniak’s complaint against the doctors, saying they acted properly. For the second time, however, the Health Professions Appeal and Review Board has rejected that decision as unreasonable, a rare event for a tribunal that upholds most of the College of Physicians and Surgeons’ decisions.

The board directed the province’s medical regulator to re-open disciplinary proceedings against the physicians, bring its own policy in line with the legislation, and make sure hospitals understand their legal obligations.

“Although the circumstances in this case are exceptional, the misconduct alleged is serious,” the board said in its recent ruling.

“The importance of this complaint transcends the conduct of the [doctors]. It is incumbent on the College to ensure that doctors understand their legal obligations … The public must have confidence that [consent laws] are understood and respected.”

A lawyer for the physicians involved — Martin Chapman and Donald Livingstone — said he could not comment on the case while it is still before the College, as did their hospital.

“Sunnybrook is following this case with interest,” said Craig DuHamel, a spokesman for the institution. The College also said it was unable to comment.

The regulator’s complaints committee had earlier ruled, though, that the doctors acted with good judgment, convinced that life-preserving measures would be futile and only exacerbate Mr. DeGuerre’s suffering. He had congestive heart failure, diabetes, hypertension and COPD, among other conditions, and had undergone a double leg amputation just before his death.

The bitter, drawn-out dispute — also the subject of a lawsuit — is one of numerous disagreements over treatment near the end of life that have wound up in Canadian courts and tribunals in recent years.

The issue typically boils down to who has the final say when medical staff feel treatment should be halted — and families want everything possible done to keep their loved one alive. The question was partly answered by the Supreme Court of Canada last year in the case of Hassan Rasouli, by coincidence another patient at Sunnybrook.

It said the hospital could not remove him from a respirator without the consent of the family and, if the parties disagreed, the matter should be resolved by the province’s Consent and Capacity Board.

‘I grabbed the oxygen bag, and I tried to help my father while they all stood there and did nothing … I just couldn’t believe it’

Mr. DeGuerre’s family had originally consented to a DNR directive, but requested “full code” after his amputation, a change noted repeatedly on his chart.

“He wanted the surgery because he wanted to live,” Ms. Wawrzyniak said Wednesday. “My father was a fighter. There were lots of things in life he was still enjoying.”

Dr. Chapman, with Dr. Livingstone’s agreement, later changed the chart to instruct staff “do not attempt resuscitation in event of cardiac arrest,” saying doing so would only increase the patient’s suffering. No one told the daughter what had happened, but physicians were not obliged under the Sunnybrook policy to obtain consent for DNRs.

Ontario’s Health Care Consent Act, however, does require doctors to get agreement from “substitute decision makers” like Ms. Wawrzyniak, and ask the Consent and Capacity Board to resolve disputes, the appeal body said.

The College’s own rules must be brought in line with the Act and communicated to hospitals so “they can review and revise their policies as required,” the board said.

An Ottawa doctor who caused a public health scare in 2011 after her endoscopy clinic failed a health inspection has agreed never to practise medicine again.

Dr. Christiane Farazli was publicly reprimanded Thursday by the Ontario College of Physicians and Surgeons for disregarding the safety of patients and ignoring the fundamental principles of infection control.

“Not only did you subject your patients to a very real risk of significant harm, your actions resulted in emotional distress and anxiety for thousands of patients as well as major costs to society for the investigations of blood-borne disease that were subsequently necessary,” the college’s disciplinary committee told Dr. Farazli in a sharply worded rebuke.

Dr. Farazli was ordered in 2011 to stop performing endoscopies at her clinic after she was found to be using improper cleaning procedures for patients treated between April 2002 and June 2011, among other actions. She publicly apologized to her patients in a written statement delivered by Ottawa Public Health officials in 2011.

On Thursday, she told the college’s disciplinary committee she would undertake to never practise medicine again. Had she not done so, the committee said, she would have faced “the most severe penalties available to the college,” which would include losing her medical licence.

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Not only did Dr. Farazli risk harming patients through improper safety and sterilization procedures, but the disciplinary committee found that she treated multiple patients at her endoscopy clinic “in a manner which can only be described as abusive.

“It is hard to think of a more vulnerable position for these patients. To treat patients in this position with gross insensitivity and disregard of their discomfort is unconscionable.”

Among other things, the college alleged that Dr. Farazli failed to provide patients with enough sedation to be comfortable and “persisted with a procedure despite a patient’s request to stop due to unbearable pain.”

Ottawa resident Rebecca Soroka, in a class-action lawsuit filed against Dr. Farazli in 2011, claimed in an affidavit that the doctor told her to “shut up” when she cried out in pain during a colonoscopy and said she was “being a baby.” Ms. Soroka also claimed the doctor took her glasses and refused to give them back and that she witnessed a nurse wiping a scope tube with what appeared to be a baby wipe.

Jean-François Farjon, an Ottawa engineer who is also a plaintiff in the class-action suit, said in an affidavit that he demanded Dr. Farazli stop the procedure because it was so painful but that she refused and told him to be quiet because he would scare other patients. He said is he afraid to have another needed colonoscopy because of his experience.

Dr. Farazli’s clinic failed an inspection done by the College of Physicians and Surgeons. She was also accused by Ottawa Public Health of using improperly cleaned and sterilized equipment.

After her clinic failed health inspections, Ottawa Public Health officials sent 6,800 letters to people who had received treatments at the clinic, warning them to get tested for HIV, hepatitis B and hepatitis C. No cases of the illnesses were found to be linked to the clinic. The province later reimbursed Ottawa Public Health $730,000 for costs related to the mass public notification.

Under new legislation, the college began inspecting out-of-hospital premises including endoscopy clinics in 2010. It was through such an inspection that problems were identified at Farazli’s clinic.

The college, which is the governing body for physicians in Ontario, accused her of acting in a “disgraceful, dishonourable or unprofessional” manner through “callous, rough and unprofessional communications with patients, maintaining inaccurate notes, proposing to engage a sales representative to assist her in a procedure when no nurse was available, and exposing patients to potential infection.”

Thursday’s hearing was based on testimony of 20 former patients. The class-action lawsuit, that has not been resolved, was filed against her in 2011.

The college’s disciplinary committee offered its sympathies to Farazli’s patients.

The college is expected to release a full written decision on the case in several weeks.

Postmedia News

]]>http://news.nationalpost.com/2014/07/24/doctor-behind-ottawa-hepatitis-hiv-scare-agrees-not-to-practise-medicine-again/feed/0stdclinicCanadians can comparison shop for nearly any service, why can’t they do the same for surgeries?http://news.nationalpost.com/2014/06/20/canadians-can-comparison-shop-for-nearly-any-service-why-cant-they-do-the-same-for-surgeries/
http://news.nationalpost.com/2014/06/20/canadians-can-comparison-shop-for-nearly-any-service-why-cant-they-do-the-same-for-surgeries/#commentsFri, 20 Jun 2014 21:14:27 +0000http://news.nationalpost.com/?p=481947

When an English hospital fired one of its heart surgeons last year, there was no suggestion of incompetence, billing irregularities or any of the other typical medical transgressions. The specialist was let go because he had allegedly fudged statistics on how his patients fared after their operations – figures published online under an extraordinary British experiment in health-care transparency.

Following a major expansion of the program last year, the success rates for thousands of surgeons are being posted for anyone to see and compare.

And now some doctors and patient advocates say it is time this country finally lifted the veil on doctor performance, too.

Canadians can comparison shop for shoes, dishwashers, smartphones and cars. Yet when it comes to arguably the most important and risky service they will ever require – invasive medical procedures – they are largely in the dark about which doctor or hospital will perform the best.

Even when a medical regulator imposes restrictions on a surgeon’s licence because of complaints, that information is often not made public. A federal agency did recently begin providing a list of basic performance statistics for individual hospitals, from rates of patients being re-admitted after heart surgery to complications following joint replacements – but experts say much more could be done.

FotoliaThere is ample indication that in medicine, like any human endeavour, skill level varies.

“If I was going to have surgery I would be keen to know the key outcome rates for the hospital and surgeon I would be going to,” said Andreas Laupacis, a physician and leading health-policy analyst. “I think it’s almost inevitable that we’re going to be reporting this more and more.”

The U.K. initiative is designed partly to help patients choose where they undergo surgery – part of a renaissance at Britain’s once-infamous National Health Service (NHS) – but it may have already had other benefits, too. In the nearly 10 years since pioneering heart surgeons began publishing their results, their overall mortality rates have dropped significantly.

“It drives a culture where you act with the patient’s best interest first and foremost, which hasn’t always happened in British medicine,” said Ben Bridgewater, the University of Manchester surgeon who spearheaded the idea. “It’s made people, everybody, focus on tidying up on every little thing, making sure you go the extra mile on everything.”

Yet some doctors here warn that publishing data on individual surgeons, while a positive idea in principle, could have dangerous unintended consequences, like motivating specialists to avoid the most difficult patients.

“If you came in with a really high-risk condition, I’d hate to think a surgeon would run for the hills because they didn’t want to take a thump to their numbers,” said Edmonton’s Dr. Dave Ross, president of the Canadian Society of Cardiac Surgeons.

Evidence is also mixed about whether patients actually make use of such information to choose a doctor or hospital when they have the chance.

There certainly is ample indication that in medicine, like any human endeavor, skill level varies, with important implications for patients. The British surgeon data shows most doctors in a similarly competent range, but with some clear outliers.

A University of Michigan study published last year found that the proficiency of 20 “bariatric” – weight-loss – surgeons whose videotaped performances were rated by colleagues varied widely. And those with the least expertise tended to have higher rates of complications and patient deaths, it suggested.

Yet in Canada, at least, results of the various types of bariatric surgery performed in assorted public hospitals and at several private clinics are kept under wraps – if collected at all, Dr. Laupacis noted in a recent commentary.

Numerous other studies over the years have indicated that patients whose doctors perform a procedure more frequently tend to suffer fewer complications. The public, though, is rarely made aware of a particular physician’s track record.

“In surgery, once you graduate, you can do whatever you want, and nobody monitors you,”said Teodor Grantcharov, a surgeon with Toronto’s St. Michael’s Hospital whose interest in patient safety led him to develop an operating-room “black box” recording system.

‘If you came in with a really high-risk condition, I’d hate to think a surgeon would run for the hills because they didn’t want to take a thump to their numbers’

Even for that small minority of surgeons whose work falls so far below standard that they are hauled before regulatory bodies, public information is spotty.

Provincial colleges of physicians and surgeons will publicize restrictions placed on doctors after they have been convicted at an actual disciplinary hearing. If restrictions are ordered based on just complaints or an initial investigation, most regulators do little to broadcast the fact. Patients suing an Ontario obstetrician-gynecologist, for instance, allege they suffered serious complications at the physician’s hands, not knowing the College had already red-flagged the doctor because of a raft of earlier complaints.

New York State appears to have pioneered public reporting of individual surgeons’ performance in the late 1990s, publishing mortality rates for cardiologists doing artery-unclogging angioplasties. Pennsylvania and Massachusetts have since followed suit.

Britain has gone furthest, though. Public reporting was first suggested in 2001 by an inquiry into a spate of heart-surgery deaths of babies at the Bristol Royal Infirmary. Cardiac surgeons had already begun collecting the data when a British newspaper successfully obtained and printed the numbers in 2005 under new freedom of information legislation. They have been posted on the Internet by the specialists’ society ever since.

Under pressure from government, nine other specialties, including colorectal, orthopedic and bariatric surgeons, began putting up their statistics last year. There are plans to add 10 more medical groups. “Secrecy is not the way forward – transparency is,” declared the head of the NHS.

The public can now, for instance, view the number and type of operations a heart surgeon has performed in the previous year and the in-hospital mortality rate of his or her patients.

Colleen De Neve/Postmedia News/FilesDr. Andreas Laupacis: “If I was going to have surgery I would be keen to know the key outcome rates for the hospital and surgeon I would be going to.”

To address the concern that death rates can be distorted by a doctor’s particular mix of patients, regardless of competence, the figures are “risk-adjusted” — statistically altered to reflect the type of people each physician treats.

There are signs of success. Since public reporting started, deaths after adult cardiac operations have dropped 25% – or by a huge two thirds if the trend toward older and sicker patients is factored in, says Dr. Bridgewater.

Physicians, though, are not entirely enthusiastic about the initiative, he conceded.

“At first, people didn’t like it, people felt it wasn’t right, being under that kind of scrutiny,” said the surgeon. “[Now] it’s kind of tolerated, if not widely embraced.”

Indeed, Dr. Ross said he heard from a senior colleague in the U.K. this week that the risk-adjusting of surgeon mortality rates is less than perfect, and that some doctors are, in fact, cherry-picking patients to keep their numbers high: the very side effect everyone most fears.

Sophisticated statistical work would need to be done, if even possible, before data on individual physicians could be made public in a fair and meaningful way in Canada, echoed Dr. Grantcharov.

A 2010 study of the three U.S. states that report surgeons’ angioplasty outcomes appeared to reinforce some of the worries. It concluded that fewer heart-attack patients – those most at risk – were receiving the potentially life-saving procedure than in jurisdictions where doctors’ results were not made public.

Dr. Bridgewater, though, points to another study that he says counters concerns about cherry picking.

It looked at 25,000 heart-bypass cases in the northwest of England between 1997 and 2005. Publishing of mortality rates for individual surgeons would start later, but those for specific hospitals went public in 2001, and the percentage of high-risk patients the facilities treated actually rose with the greater openness, researchers concluded.

A decade later, meanwhile, Canada has now begun publishing some hospital-level data itself.

‘It drives a culture where you act with the patient’s best interest first and foremost, which hasn’t always happened’

The Canadian Institute for Health Information (CIHI) started making public in 2012 a range of stats for named hospitals, including the rate of C-sections, the speediness of surgery for hip fractures, the percentage of patients who have to return to hospital following treatment for a variety of conditions, and rates of medical error.

The list is to be expanded later this year, adding statistics for hospital-acquired sepsis, or blood infection, and outcomes in nursing homes, said Kira Leeb, CIHI’s director for health system performance.

The public reporting has had some “eye-opening” effects, like prompting one mid-sized hospital to dig into why its death rates were so high, then make changes to try to lower the number, she said.

The transparency push seems to have its greatest effect on the hospitals, encouraging internal improvements, said Ms. Leeb. Whether patients themselves are using the data is less clear.

“We didn’t get a whole bunch of letters from the public saying ‘This is great, we really need this specific level of detailed information to choose our hospitals,’ ” said the CIHI official.

In focus groups conducted by the institute, few patients said they were anxious to see performance results for individual surgeons, something Ms. Leeb said is unlikely to happen soon, anyway. “Canada is a late adopter to all aspects of health data,” she said. “It’s just who we are.”

But one patient advocate said he is convinced that Canadians would like to know the skill level of the specialists available to treat them. In fact, people lucky enough to have the right connections have always tried to identify the best doctors through informal inquiries, noted Sholom Glouberman, founder of Patients Canada.

Dr. Bridgewater says the mere collecting of the data and distributing it amongst doctors may have been the biggest motivator for improvement in England. But he is also certain the public wants to see performance results – even if most do not use it to actually shop for a physician.

“It gives them reassurance about the overall level of care, it gives them an ability to choose and it also gives them reassurance that [poor results] will be acted upon,” he said. “The patients absolutely love it.”

Fertility specialists are calling for minimum qualifications for doctors offering assisted baby-making procedures, saying some people are being treated by doctors who don’t have the proper training to perform the procedures.

In a new position statement, the Canadian Fertility & Andrology Society (CFAS) says any physician offering assisted reproductive care should have the fellowship training and skills needed to care for patients safely and to recognize the “potential pitfalls and complications” that may occur.

“These complications may include severe ovarian hyperstimulation syndrome, high order multiple pregnancy, injury to internal organs, massive hemorrhage and even death,” it says.

Assisted procreation is highly lucrative. What’s more, with more women postponing motherhood, demand for infertility treatments is on the rise.

“This is about physicians training physicians to provide the highest quality of care that we have available,” said Dr. Roger Pierson, professor and director of research in the department of obstetrics, gynecology and reproductive sciences at the University of Saskatchewan, Saskatoon.

One of the biggest concerns involves the use of injectable fertility drugs, known as gonadotropins.

The drugs stimulate a woman’s ovaries to produce multiple eggs. However, in some cases, the woman “over responds,” producing so many egg follicles her ovaries grow big, fat and swollen.

Fluid can leak into the chest and abdomen. In rare cases, ovarian hyperstimulation syndrome can lead to blood clots, kidney failure or death.

Gonadotropins are frequently used with intrauterine insemination (IUI), where sperm is injected directly into a woman’s uterus; experts say the procedure is being widely practised outside fertility clinics. Last year, Ontario alone paid for 22,806 insemination cycles performed on 8,725 women.

‘If you can’t do it safely, you don’t do it’

“It’s in a load of different places,” said Dr. Carl Laskin, a Toronto fertility specialist and past CFAS president.

“[Gonadotropin IUI] is easy to do. The problem is it’s also easy to do unsafely and easy to do wrong.”

The risk of a multiple birth — twins or more — can be as high as 30%.

Blood tests and ultrasounds are required to measure hormone levels and determine how many eggs are maturing. If the woman produces too many eggs, the cycle should be cancelled.

“IVF [in vitro fertilization] clinics have the option to convert those patients to IVF,” said Dr. Jason Min, chairman of the clinical practice guideline committee of the Canadian Fertility & Andrology Society.

With IVF, the eggs are removed and fertilized in a lab dish, and the resulting embryo transferred back into the uterus.

“Outside an IVF clinic, their only recourse would be to cancel the cycle,” said Dr. Min of Calgary’s Regional Fertility Program.

But, “it may be very difficult for you to say to a patient who has just spent X number of dollars on so much medication that, ‘I have no choice but to cancel your cycle.’ ”

Egg retrievals also carry risks. “The big one is sticking your needle into an artery,” said Dr. Pierson.

“You have to have the proper sedation. You have to have the ability to recognize an ovary on ultrasound and interpret ultrasound images. You have to have the ability to use the ultrasound probe and needle.

“These are all technical skills that you don’t learn by reading a book.”

Added Dr. Laskin, “The overriding principle is always, you want to get the woman pregnant, you want her to keep the pregnancy and you want all of this done safely. And if you can’t do it safely, you don’t do it.”

Two surgeons for a major weight-loss surgery clinic have been cautioned for violating professional rules on advertising, the latest in a string of controversial disciplinary investigations triggered by one of the titans of Canada’s anti-obesity industry.

Some physicians in the field say Dr. Stanley K. Bernstein routinely makes complaints against his competitors. In at least two instances, the Ontario College of Physicians and Surgeons rejected Dr. Bernstein’s complaints as frivolous abuses of process.

“It is an extremely frustrating thing that the College can be used by someone to, in a sense, stifle competition,” said Dr. Yoni Freedhoff, a University of Ottawa professor who has had to answer a number of Dr. Bernstein’s allegations. “I don’t think the College should be utilizable as a physician’s personal policeman.”

Meanwhile, Dr. Bernstein is now on the receiving end of similar probes himself. Responding to a complaint by Dr. Freedhoff’s office manager, the regulator last year ruled Dr. Bernstein had violated advertising regulations — just as he has repeatedly accused others of doing.

The physician and entrepreneur has appealed that decision, but is facing many other complaints, as well, noted the College’s inquiries committee in its ruling.

Dr. Bernstein Diet and Health Clinics boasts 60 outlets across Canada and the United States, part of a thriving weight-loss industry estimated to generate $6-billion a year in this country.

Neither the owner nor his lawyer in the latest case, Lindsay Kantor, could be reached for comment.

Kathryn Clarke, a spokeswoman for the College, said she could not comment specifically on Dr. Bernstein’s complaints about his rivals, but said generally the agency must look into any allegation that contains evidence of wrongdoing. In a “very small percentage” of cases, it refuses to investigate because the complaint is considered frivolous and vexatious, she said.

Dr. Freedhoff said he knows of “multiple” physicians in the weight-loss — or bariatric — field who have been peppered with disciplinary complaints from Dr. Bernstein.

Among them is Dr. Chris Cobourn, medical director of the Surgical Weight Loss Centre in Mississauga, Ont.

“None of us is immune,” said the surgeon. “He goes after everybody.”

A third doctor confirmed that he and others he knows of had “felt the wrath of Dr. Bernstein,” but asked not to be named, fearing more complaints.

“The College apologizes to you, and says ‘We’re sorry we have to follow these complaints, and we know they don’t make any sense,’ ” said the doctor. “[But] it costs money, and it causes grief and stress, my heart’s racing. And it’s nothing, it’s dumb.”

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Dr. Freedhoff runs the Bariatric Medical Institute, where his own work is covered by medicare and patients pay a fee for other services. He said some of Dr. Bernstein’s complaints concerned advertising and testimonials Dr. Freedhoff employed in the past, which he has changed in response to College cautions.

One, though, accused Dr. Freedhoff of violating ad rules by taking part in an Ontario Medical Association marketing campaign — along with several other physicians. Dr. Bernstein did not complain about the other doctors featured in the OMA ads, none of whom were involved in the weight-loss industry. Another complaint focused on the fact a radio interviewer had referred to Dr. Freedhoff as an obesity “specialist” — a technical term in the medical world for physicians formally accredited in a particular field — rather than as an expert.

In both cases, the college inquiry committee concluded the complaints were “frivolous, vexatious and an abuse of process.”

In a decision last month regarding another Dr. Bernstein complaint, though, an appeal tribunal upheld the College’s decision that two physicians violated professional rules because of their link to ads for the Slimband surgery clinic.

Christopher Pike/Postmedia News/FilesDr. Yoni Freedhoff of the Bariatric Medical Institute: “I don’t think the College should be utilizable as a physician’s personal policeman.”

The marketing was focused largely on compelling testimonials from Slimband patients, and doctors are barred from being part of ads that include testimonials.

The two surgeons both perform gastric-banding operations at the Toronto-based centre. In response to earlier complaints from Dr. Bernstein, their names had been removed from the Slimband web site.

Dr. Bernstein filed another complaint last year, though, that testimonial-based marketing for Slimband was still available on a third party’s website — and mentioned the physicians.

The college agreed, said the rules had been breached and ordered Drs. Patrick Yau and Jamie Cyriac to be cautioned.

Joyce Harris, Dr. Yau’s lawyer, declined to comment on the decision, calling the cases “essentially commercial disputes.” Dr. Cyriac’s lawyer also would not comment, and Slimband did not respond to questions about the issue.

The rules allow doctors to use fact-based advertising that is not misleading and contains no superlatives, “comparatives” or testimonials. Ms. Clarke said a College discipline panel explained the problem with testimonials in an unrelated case, arguing that the patient stories can bias consumers.

“This makes their use in the health-care setting a potentially dangerous tool, increasing the chance that prospective patients will end up making poor decisions,” the committee wrote.

“There was always some company bringing them Thai curry, pizzas … a never-ending parade of delicious-smelling food,” said the University of Victoria researcher.

Such freebies are among an array of methods that drug firms employ with doctors who prescribe their products.

A major pharmaceutical company, however, revealed Tuesday it is taking a seemingly unprecedented step back from the kind of marketing to physicians that is common throughout the sector, and has raised critics’ concerns for years.

GlaxoSmithKline (GSK) announced it will stop the practice of paying certain fees to individual physicians and will no longer tie bonuses for its drug reps to the prescribing habits of specific doctors.

Some analysts offered wary kudos on Tuesday to GSK, a company that recently has faced heavy penalties for questionable marketing, and yet led the way in starting to make the industry more transparent.

“It’s a good first step,” said Dr. Joel Lexchin, an emergency physician and health-policy professor at Toronto’s York University. “The literature shows that when doctors get information from drug companies, it either has no effect on their prescribing, or makes their prescribing worse. There is no evidence it makes them better.”

U.K.-based Glaxo announced that it would end payments to individual doctors — usually specialists known as “key opinion leaders” — for giving talks on products or a disease area. Subsidies to attend conferences are being phased out, too.

The company will also stop linking sales reps’ pay to the number of prescriptions handed out by individual doctors, emphasizing instead the reps’ technical knowledge and quality of service, as well as GSK’s overall performance.

The changes are designed to ensure “patients’ interests … always come first,” Andrew Witty, Glaxo’s CEO, said in a statement.

Glaxo has 2,200 employees across Canada; the changes should be in effect here by the start of 2016, said a company spokeswoman, who asked not to be named.

She said GSK pays Canadian doctors to talk to other physicians about its products, and to help them participate in scientific meetings, activities that will end, but the spokeswoman could not say how many receive payments or at what cost.

Glaxo’s move comes in the wake of some serious trouble for the company. It was fined US$3-billion by the U.S. government last year for illegally marketing its anti-depressants for unapproved uses, and withholding safety data on diabetes drug Avandia.

And in China it is under investigation for allegedly bribing doctors and officials.

Yet it garnered positive reviews for being the first drug company to join alltrials.net, a project aiming to divulge full reports of drug trials, including negative results.

‘It’s the food, flattering and friendship that promotes the drug’

The changes announced this week seem positive, but the “devil’s in the details,” said Mr. Cassels.

He and Dr. Lexchin also noted there are still many ways even GSK could influence the profession, such as by sponsoring associations, conferences and educational sessions, and through the personal relationships reps have with physicians.

“It’s the food, flattering and friendship that promotes the drug,” said Mr. Cassels.

A 2010 review of previous studies co-authored by Dr. Lexchin concluded that doctors exposed to industry messaging tend to prescribe more drugs, raise health-care costs and make lower-quality choices.

Dr. Louis Hugo Francescutti, president of the Canadian Medical Association, said the GSK initiative was welcome, but noted his group has had a code of ethics dealing with industry interactions in place for years.

It is especially important that doctors not engage in “peer selling” — giving company-sponsored talks to their colleagues that promote products, he said.

“We don’t want practising physicians to be sales persons for either the pharmaceutical industry or medical device manufacturers,” said the Edmonton emergency physician. “It just doesn’t make sense.”

Dr. Lexchin said Health Canada should at least adopt the same kind of “sunshine” law being implemented soon in the U.S., requiring all drug-industry payments to doctors to be released publicly.

Dr. Francescutti said he did not think that was necessary, stressing that the large majority of physicians are responsible.

As reported in Monday’s National Post, Ontario’s legislature has adopted a private member’s bill that seeks to loosen draconian regulations that prevented medical practitioners from providing legitimate professional services to their spouses. The restrictions were well-intentioned, and sought to ban sexual relationships between medical professionals and potentially vulnerable patients. But when enforced to their full effect, the law resulted in absurd cases where chiropractors were losing their licences for performing spinal adjustments on their significant others and dentists polished their spouse’s teeth at their own risk. Preventing sexual exploitation is a worthwhile goal, but this law simply went too far.

The private member’s bill, which was introduced by Progressive Conservative MPP Steve Clark and received the support of his party and the governing Liberals, simply adds two entirely reasonable exemptions into the existing legislation, that the medical colleges for reach regulated provision may choose to adopt at their own discretion: First, that medical professionals are permitted to perform their normal services upon their spouse, including common-law partners; and second, that sexual activity may not be suggested or carried out during such a professional service (an entirely reasonable, if somewhat obvious, requirement).

It is to be hoped that all of the medical professional colleges in Ontario quickly adopt these measures, as the dental college has already signalled it will (dentists had argued particularly strongly for these exemptions to be added). But the Ontario College of Physicians and Surgeons has said that it will not, believing that the protections against sexual exploitation are too important to set aside.

With all due respect to the College, any marriage that is so dysfunctional as to include sexual abuse of a spouse by their partner will not be solved by red tape governing medical ethics. Mr. Clark’s bill strikes the right balance between protecting the vulnerable and not needlessly interfering in the romantic lives of Ontario’s doctors, dentists and chiropractors.

In a recent position statement, the Canadian Society of Obstetricians and Gynecologists argued that immigrant patients’ expressed wishes to be treated by a doctor of their own sex, race, culture or religion — reportedly a common phenomenon — should not be reflected in our country’s health-care policy. These professionals feel services should be provided by the most qualified personnel available, period.

As Tom Blackwell reported in the National Post this week, some doctors disagree with this attitude, which they regard as excessively rigid. Dr. Kevin Pottie, an Ottawa doctor who helped to draft the Canadian Guidelines on Immigrant Health, for example, is sympathetic to immigrants’ demands, saying, “The experience of a lot of vulnerable people, marginal people, is they are faced with a lot of discrimination, they have a lot of issues with trust, they may only trust their community.”

As someone who has worked with immigrants for decades, I am somewhat skeptical about Dr. Pottie’s assumption that this is a “trust” issue. Indeed, what I have found is that many immigrant patients have had such negative experiences with health care in their countries of origin that, once in Canada, they prefer treatment from someone outside their ethnic community. And many female immigrants in particular may have good reasons to prefer doctors from other cultures.

I am a South Asian immigrant to Canada. I am a counsellor and educator who has worked intimately with South Asian victims of abuse for 30 years. I hold workshops for health care professional to guide them on culturally embedded practices related to health and family structure. Among the issues we discuss are patriarchal control over female sexuality, gender inequalities, and the culturally ingrained preference for sons.

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There is now extensive literature on immigrant women and their attitudes relating to health care. The most common concern South Asian women identify is the insistence of husbands (and/or his family members) that they accompany them into the examining room. This is a practice tolerated by many doctors from the South Asian community, even when language is not a barrier. This inhibits women from speaking freely about their symptoms or feelings.

I am not critiquing the medical expertise of South Asian doctors. And it is important to note that South Asian female doctors have been in the forefront of educating the larger South Asian community about gender inequity and its impact on women’s health, empowering women to take control of their health related concerns and sexuality. I also have witnessed some doctors take a stand against the demands of women’s extended families, in particular in cases where a specialist colleague happens to be male and not from the South Asian community.

We would have no sympathy for whites who refused medical care from blacks. Why should immigrants be held to a lesser standard?

In areas of Canada where there are large populations of South Asian immigrants (some of whom may not speak English or French), there typically are hundreds of doctors of both sexes, who speak different South Asian languages, available to the community. Members of the community usually are well aware of their location, and women who prefer to see female doctors from their own community can go to these professionals for their health needs.

But in health units where the patients and medical personnel are diverse, patients should not have the right of refusal of service based on race, culture or religion. We would have no sympathy for white people who refused medical care from black people — and according to many physicians, that too is a common phenomenon — even if they insisted their health depended on it. We should therefore not encourage analogous forms of medical apartheid disguised as compassion for immigrants. The position taken by the Society of Obstetricians and Gyncecologists is both fair and reasonable.

National Post

Aruna Papp is a Toronto-based Educator and advocate. She provides training on preventing honour-based violence. She is a Research Associate at the Frontier Centre for Public Policy, and is the author of Unworthy Creature: A Punjabi Daughter’s Memoir of Honour, Shame and Love.

Montreal — The Quebec college of physicians has issued a warning to doctors to stop performing virginity tests, a practice linked to bridal purity and family honour.

Gynecological exams for virginity certificates contravene the profession’s code of ethics on several grounds, including breaching patient confidentiality, said Charles Bernard, president of the Collège des médecins, in an interview.

The practise is outrageous, repugnant, irrelevant and unacceptable, he said.

“Imagine a doctor who does a gynecological examination with the sole purpose of … it goes beyond the imagination. And it’s degrading to women,” Dr. Bernard said.

The College was responding to a study by two ethics specialists from the Université de Montréal who were called upon by a school nurse and other health professionals after five incidents of families seeking virginity checks in the last 18 months in Quebec.

‘It’s a taboo practice and it’s hidden’

The ethicists were initially contacted by a clinic nurse who was asked by a young woman in her 20s during a routine medical checkup whether “she was still marriageable.” She had asked the nurse to check if her hymen (a piece of tissue that lines the vaginal opening) was still intact.

Two weeks earlier, the researchers got a call about an adolescent who had been forced to undergo a chastity test. The distressed girl raised the issue with her school nurse, who reassured her that such things are not done in Quebec — but then, the girl’s family forced her to go to a clinic.

Some doctors have admitted to providing fake proof of virginity, without having performed a chastity test, “in the interest of harm reduction to save a girl’s honour,” said ethicist and UdM researcher Marie-Ève Bouthillier,.

There are no statistics on the frequency or scale, she said, “because it’s a taboo practice and it’s hidden.”

“But this is a problem and these are not isolated cases,” added Claire Faucher, assistant clinical professor at UdM’s faculty of medicine, who, along with Dr. Bouthillier, conducted the research that led to the College guidelines.

Earlier this year the Paris-based Organization for Economic Cooperation and Development (OECD) released the results of a survey of average waiting times for medical care in 25 countries. This was not a shining moment for Canada.

Waits for most medical services are far longer here than in most of the comparator countries. This is simply the latest evidence seemingly supporting the notion of a “doctor shortage” that has been a recurring theme in the Canadian public discourse for the past 20 years. But a closer look at the evidence shows that, if anything, our problem will soon be too many doctors.

Over the past 15 years, first-year medical school enrollments in Canada have almost doubled, from 1,575 in 1997-98 to about 3,000 in 2012-13, during which time the population increased by less than 25%. The number of foreign medical graduates entering practice in Canada annually has also more than doubled since the year 2000. Over that same period, the number of Canadians who obtained their medical degrees internationally and entered practice in Canada annually has increased 250%. The Canadian Institute for Health Information (CIHI) reports released this week indicate that between 2008 and 2012 the number of physicians rose three times faster than the growth of the overall population, and for the sixth year in a row, the number of physicians per population has reached a new peak and is continuing to rise.

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More doctors does not always translate directly into more care provided — not every doctor works in a hospital or clinic, or puts in the same hours as another might. But these figures highlight some troubling trends. We are only just beginning to see the effects of the expansion in domestic training capacity. In other words, we are in the early stages of a dramatic expansion in physician supply that will continue for decades. Contrary to the continuing doctor-shortage rhetoric from ill-informed or interested parties, a “physician glut” appears already to be in the pipeline. Even our aging population will not need all these new physicians — every study ever done has found that demographic change adds only about 0.5% annually to per capita use of services.

Meanwhile, average medical expenditures per physician in Canada (adjusted for fee changes) have been rising, not falling, even as the overall supply of trained physicians expands and the average hours worked by each doctor falls. If average hours of work are falling, how is it that adjusted payments per physician are rising? Either physicians are delivering more services per hour, or their fees are actually rising much faster than the official fee schedules show (or both). And if they are finding ways to deliver more care, in spite of putting in fewer hours, how is it that we need more doctors?

The problem is too many doctors, not too few

Some patients continue to have difficulty finding family doctors, and face excessive waiting times, particularly for certain specialists and some diagnostic tests and surgeries. These are real problems. But evidence is beginning to emerge of Canadian-trained doctors who cannot find work in their home country. We suspect this is the beginning of a new and unfortunate trend.

An estimated 3,570 Canadians are currently studying medicine at schools in the United Kingdom, Australia, Poland, the Caribbean and elsewhere. Assuming a four-year training program, these soon-to-be-doctors represent a potential increase to domestic supply of nearly 900 new physicians per year, a dramatic increase from the current rate. To enter practice they must not only pass Canadian qualifying examinations and complete residency (specialty) training here; but there are not enough residency positions to meet expected demand. Again, the problem is too many doctors, not too few.

Canada’s health services need to recognize the reality of the new domestic training situation. The goal shouldn’t be more doctors, but getting the physicians we already have (or soon will) the training, expertise and resources to ensure they can find work where Canada needs them.

National Post

Morris Barer is an advisor with EvidenceNetwork.ca, Professor in the Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, UBC, and the lead for the western hub of the Canadian Health Human Resources Network (CHHRN). Robert Evans is an emeritus professor of economics, UBC.

Meet the newest scapegoats in the rising cost of healthcare: doctors. A study released this week by the University of Calgary School of Public Policy estimates that physician pay has increased by 30% in constant dollars since the turn of the millennium. In 2010-2011, the average practitioner earned $307,482; after expenses such as rent, secretarial assistance and the like, he or she netted $248,113. Doctors now earn four-and-a-half times the average Canadian wage, up from three and a half times in 2000. Compensation was highest in Alberta and Ontario, lowest in Atlantic Canada and Quebec.

Economics professor Hugh Grant, the report’s co-author, offers several prescriptions to “fix” this situation. Among them: Doctors should stop receiving large pay increases; and provinces should allow less credentialed — and less well-remunerated — health care providers, such as nurses and pharmacists, to deliver more services. As for doctors, “If physician associations want to maintain their professional autonomy, they are going to have to be more responsible.”

Grant’s view echoes a similar critique made by Stephen Lewis and Terrence Sullivan in a report recently prepared for the Institute on Public Policy: “The only way to permanently de-escalate health care spending is to do less with less … The only way to contain health care spending is to change the deals we make with doctors.”

In other words, doctors should earn less money, patients should receive less care, and less qualified people should provide it. This logic is the same as that of governments that delist services or mandate the prescription of certain brands of drugs (usually generics) because they are cheaper.

It is, in a word, rationing. And study after study shows that rationing health care (or any good) doesn’t work.

The Fraser Institute’s most recent annual tracking of wait times in Canada found that they have increased by 91% between 1993 and 2012. This, despite the fact that spending on health care increased more than the rate of inflation and population growth, or other budgetary items.

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Current deals with doctors are based on a fee-for-service model, which pays physicians on the basis of the number of procedures they perform or patients they see. Detractors claim that it encourages doctors to spend less time with patients, order unnecessary tests, or prioritize “prescriptions over conversations.” They argue that by moving to a salaried approach, for example, doctors would be freer to practice higher-quality medicine.

But that ignores the real problem: Canadian health care is delivered by a monopoly system. When the state is the only “paymaster,” the physician — like any employee — reacts accordingly. Without a free market for their services, doctors cannot charge the rate their services would actually command. They cannot choose to work at the pace that they prefer.

And, equally importantly, their patients cannot choose what kind of service to receive.

In Quebec, where state compensation for physicians is the lowest in the country, more and more doctors are opting out of the public system altogether, opening private clinics for basic services

Opening up the public system to competition would allow patients to choose between routine and in-depth care. If you need a vaccination for your child, or a prescription for a minor malady, you might be perfectly happy with a quick visit to your local public GP. Patients seeking a more comprehensive annual checkup, or suffering from a mysterious malady, may be willing to pay a private doctor to take the extra time — but under the current public-monopoly system, most of them cannot opt for this level of care.

Some can, of course, depending on income and geography. The very wealthy have always been able to afford to travel outside the country for health care. Those in certain provinces can also do so; in Quebec, where state compensation for physicians is the lowest in the country, more and more doctors are opting out of the public system altogether, opening private clinics for basic services. In Ontario, private clinics offer services that medicare does not provide, such as comprehensive assessments, for a fee. But patients cannot insure themselves for these services, and so they remain outside the reach of most of the middle class.

This would change if governments opened up the health care system to public-private competition and choice — for both doctors and patients. If doctor pay is driving up health care costs, the answer is not to cap compensation, make physicians salaried employees, or downgrade quality of care. Ending the monopoly-payer system would give doctors the incentive and flexibility to earn the compensation they seek, while delivering the quality of care patients demand.

Nearly four years after staff at Toronto’s Saint Michael’s Hospital started slipping an anti-psychotic drug into a woman’s orange juice while treating her for lupus, Ontario’s highest court has tossed aside the ruling that allowed her to be drugged against her will, in part because the psychiatrist who diagnosed her with schizophrenia admitted he was “making parts of [her symptoms] up.”

In a sharply worded ruling, the Court of Appeal said there was “no evidence” the woman ever agreed to medication, and overturned the Consent and Capacity Board’s “unreasonable” finding that the woman was mentally incapable of doing so.

“It certainly is a forceful ruling,” said Anita Szigeti, lawyer for the woman, Amy Anten. “It’s important for her personally. In my respectful submission, it’s also very important — and the court appears to have agreed by considering the matter on its merits — to give the Consent and Capacity Board, and also the first appellate level of reviewing court, some guidance on how to really weigh the evidence that goes to the heart of the Charter-protected right of the person against forced treatment.”

The judgment clarifies what kind of evidence to prove a person’s incapacity will withstand legal scrutiny, and it reinforces a patient’s right to refuse medication, which the Supreme Court of Canada upheld in 2003.

Ms. Szigeti also said despite that top-level legal guidance, a “pervasive paternalism” has revealed itself in medical institutions, such that now it is “absolutely commonplace for a physician to just give his or her opinion” that patients cannot make choices about their own treatment.

“You risk rubber-stamping a physician’s finding of incapacity, without ultimately a shred of evidence to support it,” she said.

The new ruling, released on Monday, found the anti-psychotic schizophrenia drug Risperidone appears to have been administered without Ms. Anten’s knowledge in orange juice “to improve her compliance” with the treatment regime. It was later injected with her knowledge.

It finds that Dr. Shree Bhalerao, a psychiatrist at Saint Michael’s Hospital, gave “confusing” testimony about his initial exam of her, and could not justify his decision to re-categorize her psychosis as schizophrenia, based on a sketchy history. The court was particularly critical of his explanation that the medical team “tried our best to assure her that [her delusions about people attacking her] weren’t happening, but again, I mean it’s her word against ours and we tried our best to alleviate that by using that kind of floor [sic] of medications.”

‘You risk rubber-stamping a physician’s finding of incapacity, without ultimately a shred of evidence to support it’

Ms. Anten, whose age is not specified but is older than 40, testified she did not believe she was ill when she was hospitalized in November 2009.

“I feel numb mentally and physically,” she testified. “I feel more angry and more depressed and I do start feeling as if people are harming me. Although I did before, but it appears from what [Dr. Bhalerao] said that I was being given medicine before I even realized it. So it could be as a result of this medicine entirely that I have made such, um, made such admissions that people were harming me but there was a particular patient who was here and she left recently about a half a week ago, and I believe she was harming me while I was sleeping.”

The ruling criticized the Consent and Capacity Board for finding that, as a result of her illness, Ms. Anten was unable to appreciate that medication would benefit her, and that she was unable to compare her fears of side-effects with “the fact that without treatment the psychosis would continue unabated,” as the board put it.

“There was no evidence to support such a finding,” the court concluded. “To the contrary, while there was unchallenged evidence from [Ms. Anten] of the side-effects of treatment, [Dr. Bhalerao] offered no evidence of any benefit.”

The court declined to order a new hearing, because Ms. Anten has been the subject of subsequent capacity hearings, with various outcomes. “In these circumstances, nothing would be gained by ordering a new hearing,” wrote Justice Marc Rosenberg for a three-judge panel.

CALGARY — Concerns over the aging population and the rising cost of pharmaceuticals may be distracting from one of the fastest-growing healthcare expenditures in Canada: doctor pay.

A report released Tuesday by the University of Calgary School of Public Policy estimates the average paycheque earned by a typical Canadian physician has risen by about 30% in constant dollars over the past decade.

Since 2000, the average doctor went from earning three-and-a-half times the typical worker’s salary to four and-a-half times that amount, the report said.

Professor Hugh Grant, an economics professor at the University of Winnipeg, said fears of doctor shortages and brain drains have spooked provincial governments into wage hikes that have far outstripped the gains made by the average Canadian.

“I think most people acknowledge now that the physician shortage was highly exaggerated,” he said. “There are enough physicians in Canada; there are lots of physicians in Canada.”

Provinces could ameliorate shortages by being more flexible on scope of practice rules; by allowing nurses and pharmacists, for example, to deliver more services, he said.

In the meantime, the wage differential between American and Canadian doctors has shrunk, reducing south-bound brain drain.

“Your opportunity to move to the U.S. has really contracted a lot with some of the practices the HMOs have adopted recently, so there just aren’t the opportunities there,” Mr. Grant said. “When the Canadian dollar was 65 cents, U.S. salaries looked terrific. When it’s near par, it’s not so good … we now have been seeing a reverse flow, there are more physicians coming to Canada than leaving Canada.”

That shift may give provincial governments the political leverage to bring doctor remuneration in line with increasingly tight budgets. A report also released on Tuesday from the conservative Fraser Institute suggests healthcare costs in Canada are growing at faster rate than shelter, food and the average income. A family of two parents and two children with an average income of more than $113,000 can expect to pay more than $11,000 in taxes to the country’s publicly funded system.

‘‘The fact is, Canadian families pay thousands of dollars in taxes every year to cover the cost of public health care insurance. And that cost rose 1.5 times faster than average income over the past decade,” said Nadeem Esmail, Fraser Institute director of health policy studies.

The School of Public Policy, University of Calgary/HandoutUniversity of Winnipeg economics professor Hugh Grant: “I think most people acknowledge now that the physician shortage was highly exaggerated,” he said. “There are enough physicians in Canada; there are lots of physicians in Canada.”

Physician pay is a tricky matter that is difficult to compare directly: doctors are essentially contract employees for their respective provinces. Each province negotiates a fee per service provided. Doctors then have to pay for their own overhead, including rent and administrative help.

A report for the Canadian Institute for Health Research found that doctors made, on average, $307,482 in 2010-11. Physicians in Alberta were paid the most. Ontario doctors came in second, while those in the Atlantic provinces and Quebec earned the least.

However, those figures didn’t take doctors’ costs into consideration.

Mr. Grant’s report said doctors netted an average income of $248,113 in 2010.

Physician compensation comprises a substantive total of the overall expenditure allocated to healthcare in Canada; Dr. Grant said doctor pay eats up about 16% of total expenses at the federal level and a much higher percentage of provincial healthcare budgets.

Alberta, for example, budgeted $3.4-billion for physician compensation and development in 2013-13 — more than 8% of the province’s total expenses.

‘We now have been seeing a reverse flow, there are more physicians coming to Canada than leaving Canada’

Dr. Michael Giuffre, president of the Alberta Medical Association, said the school of public policy’s report doesn’t properly take costs and incentive programs into consideration.

“If you look at the [net] physician income curve and compare it to the consumer price index, those curves are superimposable,” he said. Growth in doctors’ salaries is not out of line with those of other health professionals, he added.

Further, part of the reason why Alberta’s wages are so high is because the provincial government introduced incentives to encourage doctors to work there during boom times. In recent years, doctors have accepted 0% wage hikes.

Indeed, facing tightening budget constraints, both the Alberta and Ontario governments have made moves to rein in doctor pay.

“We’ve already moved beyond the recommendations and findings of this particular study,” he said.

Dr. Giuffre also said the report had failed to consider the impact of U.S. health care reform, which is expected to insure an additional 30 million Americans by 2014.

“The expectation is that there will be recruiting groups from the U.S. looking at Canada to fill those holes.”

]]>http://news.nationalpost.com/2013/07/30/doctor-salaries-have-shot-up-30-in-past-decade-over-fears-of-physician-shortage-brain-drain-to-u-s-report/feed/2stddoctors-1The School of Public Policy, University of Calgary/Handout